Operating Note

Section-I:
Patient’s Name Age/Sex
Bed/Room No.
Date of admission Admission No.
Date of Operation
Emergency/OPD No.
Referring Consultant
Pre-op diagnosis (ICD Code: )
Post-op diagnosis (ICD Code: )
Surgeon
Assistant/s
Anesthetist/s
Anesthesia given
Name of the procedure (ICD Code: )
Duration of procedure
Section-II: To be filled by Surgeon or First Assistant
1. Procedure:
The procedure describes all steps from skin incision (or entry of endoscope) till the closure of
wound (or removal of scope)- name of the procedure is also mentioned (if known).
It must also mention the following:
A. Anatomical site surgery performed.
B. All types of sutures used and the layers of tissues closed by them.
C. Sites and types of drains inserted.
D. Type and serial no of prosthesis used.
2. Findings:
A. Must describe all that is found relevant to the pathological nature and extent ofdisease.
B. Must also mention if encountered any unexpected pathology or intra -operative
complication.
3. Post- op instructions:
A. Whether to send patient/client back to ward/room or ICU from Recovery Area.
B. Any specific instructions to be followed immediately in the recovery area.
C. Instructions for next 24- 48 hours (specific management and treatment).
D. Instructions regarding pathological specimen - specific test required - from where.

Surgeon's/first assistant's signature

Section-III: To be filled by scrub nurse
1. Intra operative estimated blood loss
2. Intra operative IV fluid/blood transfused
3. Intra operative urine output (if catheterized)
4. Whether swab and instrument count was complete

Scrub nurse name and signature